Health Care Privacy Forms

The following forms are used to submit requests mentioned in the Notices of Privacy Practices for Cigna HealthCare and Cigna Home Delivery Pharmacy.

To make a request, print and complete the appropriate form and mail it to the address indicated on the form.

If you want to obtain a copy of your health care information that Cigna maintains, use this form:Request for Access to Protected Health Information English | Español | Chinese

If you want to amend or correct health care information that Cigna created, use this form:Request to Amend Protected Health Information English | Español | Chinese

If you want to learn whether Cigna has released any of your health care information to a third party, use this form:Request for Accounting English | Español | Chinese

If you want to limit who your health care information is released to or how it is used, use this form:Request for Restriction of Use English | Español | Chinese

If you want to receive Cigna correspondence at a confidential address, use this form:Request for Confidential Communications English | Español | Chinese

If you want to identify someone else who will make health care decisions for you, use this form:Request for Personal Representative English | Español | Chinese

If you want to disagree with Cigna's denial of your request to amend your health care information, use this form:Statement of Disagreement-Amendment Request English | Español | Chinese

If you want to either request a change to or cancel any of the above requests, use this form:Change/Revoke Request - English | Español | Chinese

If you want to allow someone else (such as a spouse, friend or attorney) to access your health care information, use this form:Authorization for Disclosure of Protected Health Information English | Español | Chinese

Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC). In Arizona, individual HMO plans are insured by Cigna HealthCare of Arizona, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Group Universal Life (GUL) insurance plans are insured by CGLIC. Life (other than GUL), accident, critical illness, and disability plans are insured or administered by Life Insurance Company of North America, except in NY, where insured plans are offered by Cigna Life Insurance Company of New York. All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico.

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